| NPI | 1629073929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX J0445) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301052929) |
| Enumeration Date | 2005-06-15 |
| Last Update Date | 2010-07-28 |